Multidisciplinary pelvic symptomatology, body pain maps, and overlapping pain syndromes are emerging as relevant to patient evaluation in pelvic floor disorders, especially those with pelvic pain.

We have developed a self-reported “Autonomic Score” (e.g. Postural Orthostatic Tachycardia Syndrome [POTS], palpitations, post-traumatic stress disorder [PTSD], abdominal bloating) and a “Neurological Review of Systems” (e.g. intermittent catheterization, balance problems, nerve pain from spine including sciatica and herniated disc) as part of an electronic multidisciplinary patient intake form aimed at characterizing patients with pelvic health concerns.
Autonomic scores and neurological ROS were collected in new patients presenting to a Urology-based Urogynecology and Reconstructive Pelvic Surgery (URPS) and Multidisciplinary Pelvic Pain clinics. Unpaired t-test, chi-squared analysis and regression analysis were used to correlate autonomic scores and neurological ROS to neurological symptoms, pelvic symptoms, report of pushing to void, pelvic pain, quality of life scores such as the American Urological Association quality of life (QOL) score and the Genitourinary Pain Index question 9 regarding QOL (GUPIQOL q9), depression and anxiety measured by the PHQ4 (Patient Health Questionnaire), transgender identity, sexual activity, orgasm intensity, sexual health inventory for men question one (SHIM q1) (hardness), SHIM overall score and sexual satisfaction and neurological symptoms.

600 sequential patients (526 female, 63 male, and 11 transgender) completed 100% of the intake.

The autonomic score was significantly higher in those with with pelvic symptoms (mean 5.1 ± 5.1 versus 2.5 ± 2.9, p<0.001) including pushing to void (mean 3.67 ± 4 versus those who did not mean 8.5 ± 6.2) (p<0.001) and pelvic pain (mean 6.4 ± 5.7 versus 3.0 ± 3.2, p<0.001). Higher autonomic scores correlated significantly with a worse (higher) AUAQOL score (R2=0.061, p<0.001) and worse (higher) GUPIQOL q9 (R2= 0.042, p<0.001) as well as anxiety and depression (PHQ4) (R2=0.17, p<0.001), and neurological symptoms (R2=0.60, p<0.001).

The autonomic score was significantly higher in those reporting transgender gender identity (mean 9 ± 6.7), compared to biological females (mean 4.5 ± 4.8) and biological males (3.9 ± 4.4) (p<0.001). 

There was no significant difference in the autonomic score with respect to sexual activity (mean 4.6 ± 5 versus mean 5.4 ± 5.2, p=0.111) or orgasm intensity in sexually active patients (N= 278, R2 = 0.00, p=0.842), SHIM q1 (hardness) (R2=0.01, p=0.903) or overall SHIM scores in sexually active men (N = 49, R2=0.0, p=0.533). Interestingly, those with higher autonomic score had higher sexual satisfaction scores (R2=0.032, p<0.001).

The neurological ROS was significantly higher in those with a history of trauma (mean 4.4 ± 2.9 versus 2.0 ± 2.4, p<0.001) and in those with localized pelvic pain (mean 10.4 ± 7.1 versus 5.4 ± 5.7, p<0.001). Orgasm intensity was not significantly different in those with a higher neurological ROS (R2 =0.00, p=0.164).

Autonomic symptomatology is highly correlated with presence of symptoms relevant to practice in pelvic health and pain. Neurological symptomatology is highly correlated with a history of trauma and localized pelvic pain. Interestingly, sexual function is well preserved in both groups. Appreciating systemic factors as part of a holistic approach to pelvic health can ensure a proper diagnosis and correct subsequent treatment, for example unappreciated neurological disease and coexisting pelvic symptomatology.